THIS FORM MUST BE ENTIRELY COMPLETED IN ORDER TO PROCESS YOUR CLAIM COBB COUNTY SCHOOL DISTRICT EMPLOYEE REPORT OF WORK RELATED ACCIDENT

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1 THIS FORM MUST BE ENTIRELY COMPLETED IN ORDER TO PROCESS YOUR CLAIM COBB COUNTY SCHOOL DISTRICT EMPLOYEE REPORT OF WORK RELATED ACCIDENT (770) FOR WORKERS COMPENSATION (678) Office Fax Employee SS# DOB Age Sex Home Address City State Zip Tel# Height Eye Color Marital Status Hand Dominance Weight Hair Color Widowed Left Right School/Dept. Employee Occupation/Title Smoker? Yes No Accident Date Time Date Reported Accident Location Body Part(s) Injured Describe the Accident (Indicate Left and Right) Witnesses Tel# *ATTENTION: IF MEDICAL TREATMENT IS SOUGHT IT MUST BE WITH AN APPROVED PANEL PHYSICIAN* Acknowledgement - I have received the Panel of physicians, signed and attached a copy indicating my choice Yes No Medical Treatment? Yes No Name of Treating Doctor/Clinic: Taken via Ambulance? Yes No Left Work Due to Injury? Yes No First Day Out of Work Primary Care Physician Name Tel# Prior Medical Treatment? Have you had prior injury or condition to injured body part(s) Yes No If yes, explain How Can Future Accidents Be Prevented? (Mark all that apply) Employee Training Proper Use of Equipment Improve Task Procedures Improve Work Area Equipment Correction Removal of Hazard Use of Personal Protective Equipment Provide Hazard Warning Enforce Policy/Rule Other Explain: Employee suggestion(s) for preventing similar accidents: Supervisor suggestion(s) for preventing similar incidents: Employee s Signature Date Supervisor s Signature Tel# Date NOTE: CONTACT RISK MANAGEMENT IMMEDIATELY IF MEDICAL TREATMENT IS REQUIRED. PLEASE SUBMIT SIGNED EMPLOYEE REPORT OF WORK RELATED ACCIDENT FORM, THE SIGNED MEDICAL RELEASE AND COPY OF PANEL OF PHYSICIANS WITH EMPLOYEES CHOICE OF DOCTOR INDICATED AND SIGNED WITHIN 48 HOURS. *Please maintain a copy of this form for your records. Revised 11/2018

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6 Cobb County School District Risk Management Department Office (770) Fax (678) MEDICAL RELEASE AUTHORIZATION FORM Please submit signed medical release form, as well as the Employee Report of Work Related Accident and signed copy of Panel of Physicians received indicating choice of doctor if treatment is sought. Send to the Risk Management Department within 48 hours of injury. A total of 3 forms should be submitted to Risk Management. Keep a copy for your site files. Release of Medical Information: I authorize the release to my employer and Workers Compensation Company all records relevant to my disability and my claim for disability or Workers Compensation benefits, including, but not limited to, medical diagnosis, prognosis, treatment and periods of hospitalization. It is understood that the Risk Management Department will use the information to verify my disability and determine my eligibility of appropriate benefits. This authorization applies to physicians and other health care providers, hospitals, clinics, insurance companies, Workers Compensation carriers and organizations administering benefit programs. This authorization will remain in effect throughout my claim for Workers Compensation benefits. A photocopy of this authorization will be as valid as the original. Panel of Physicians: I have received a copy of the Bill of Rights for the Injured Worker, as well as, the Traditional Panel of Physicians. Employee s Signature Date Please Print Name 11/2018

7 Carlisle Medical/RESTAT Making a Difference Workers Compensation Prescription Information M-F 10am-6pm CST Please present this information to any participating pharmacy for prescription processing Employee Name: (Please Print) Social Security Number (used as Member ID) : - - Date of Birth: Date of Injury: Plan/Group Number: W 908 Member Number: Employee s SS # - - (plus the injury date, NO dashes MM/DD/YY) RESTAT Bin Number: Person Code: 000 Our employee has been injured in a work related accident. Please use the information above to process prescriptions for Cobb County School District. If you have questions, please call our office. Thank You. Donna Davidson, Medical Claims Adjuster Office ~ Fax ~

8 COBB COUNTY SCHOOL DISTRICT Workman s Compensation ~ Risk Management Mileage Reimbursement Form Fax # EMPLOYEE NAME: DATE STARTING ADDRESS (use complete address with city/zip) DESTINATION~ ADDRESS (Ie: PT, Dr Appt,etc.-use complete address with city/zip ) MILES Roundtrip One Year Deadline With Regard to Medical Expenses Section 4 of SB 233 also creates O.C.G.A (c)(4), which provides for a one year deadline with regard to medical expenses. It states that, Notwithstanding any other provisions of this subsection, if the employee or the provider of healthcare goods or services fails to submit its charges to the employer or its workers compensation insurer within one year of the date of service of the issuance of such goods or services, then the provider is deemed to have waived its right to collect such charges from the employer, its workers compensation insurer, and the employee.